HomeMy Public PortalAbout5127 KAUFFMAN AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION" 20-0046 DPW 9189 ��
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I j+ereb' affirm that l have a Certificate of consent to self insure, L�
��0 �®NFORp�G�1�10�' '
.Insurance,.or a certified. HEATING-VENTILATING AIR CONDITIONING
ME- REEN
'f a certificate'of Worker's Compensation ' .
copy thereof(Sec.3800 Lab.C.)
Policy No. _Z�; Company t 19COUNTY OF.LOS ANGELES DEPT OF,'PUBLIC WORKS BUILDING AND SAFETY_ DIV.
Certified copy'is hereby furnished.
Certified copy is filed with the':county bullding'inspection FOR APPLICANT'-TO FILL IN BUILDING
de art ent.'. , 1 (PRINT OR TYPE ONLY)
p
/ 7. .� LOCALITY =
Date' (J > Applicant ��J
NO. TYPE OF APPLIANCE OR EQUIPMENT' FEE.
'CERTIFICATE OF EXEMPTION FROM WORKERS', NEAREST
COMPENSATION INSURANCE CROSS ST.
ABSORPTION UNIT„BTU ASSESSOR,
(This section need not'-be_cohripleteclAf the,.work.involved by the MAP BOOK PAGE, , PARCEL
permit is for,-one hundred dollars($1.00).or less.) FAIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that;in the performance of thepwork for which this permit
is issued I;shall not'employ'any person in any•manner so as to BOILER;BTU
become Subject toAhe Workers'Compensation Laws.
, • COMPRESSOR,BTU `
APPROVALS SIGNATURE
Date Applicant VENTILATION SYSTEM uiE` .
APPRO '� � DATE INSPECTOR'S S T
NOTICE TO APPLICANTIf, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers' Compensation
p y. I iEVAPORATIVE COOLER
provisions of the Labor.Code`;.you must•forth'ith comply with such FINAL
provisions or this permit shall..,be deemed revoked..' FURNACE:, i, FAU RKY6 V
_ LICENSED CONTRACTORS DECLARATION �' FLOOR BTI) VAI-IDATION
hereby affirm that I am licensed under provisions of Chapter 9 .SUSPENDED UNIT 4v.
(commencing with Section 7000) of-'Division 3 'of Business and. HEATER:,. WALL
Professions Code,'and my license Is In fulC force and effect.
`'.
License Number - / LIc.:Class ..
fes-.
Contractor ate t l isiL
Plan check fee` ,
0 f am exempt under Sec. •� - I'#�°+
K
tea_
,
B.&P.0 for this reason PERMIT ISSUING FEE$ (
I O
Date
TOTAL FEE W,
Signature ',
PLAN CHECK APPLICANT GP)
OWNER-BUILDER DECLARATION - t�_
1 hereby affirm that I am exempt,from the Contractor's License taw NAME _ t 'i
for the following reason.(Section 7031.5, Business and Professions.
•Code)
ADDRESS
❑- .I, as owner of the property; or my'employees;rwith wages' r• =
as their'sole compensation, will+dorthe work and the CITY Y, TEL:NO.
structure is not intended or offered for sale (Section 7044,
Business and Professions Code),''' OWNER
I, as owner-'of the property, am exclusively contracting MAIL-. _
with licensed contractors to construct the p71.
roject (Sec- ADDRESS � .•
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY . CITY TEL.NO:_
1 hereby.affirm that there is a construction lending agency for j 4..
the performance of'the,•work for which this'.permit Is Issued CONTRACTOR /(y� R
(Sec.3097,Civ. C.).
ADDRESS &;NJ 7,4 . .. ..
Lender's Name
. CITY' TEL.NO:
Lender's Address STATE LIC., '
I certify that'I have'read this application and.state that the above' LICENSE NO. CLASS.
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
representatives of this County to enter upon the above-mentioned
pr�NPA*IURE �LICAA1110.
pection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE.
AGENT f DATE
` COUNTY OF LOS ANGELES TEMPLE CITY # 0508 MECHANICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ME 0508 1211090003
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT: -
(LEGAL ID: - FEES PAID BUILDING ADDRESS:
ITR: 15683 LT: 38 1 5127 KAUFFMAN AV I
1 IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: ( TEMP CA 917803946
(ASSESSOR INFORMATION NUMBER: 1 •''; ', . � NEAREST CROSS STREET: "-
18589-011-010 '-1-01 PERMIT ISSUANCE FEE •' 27480 THOMAS PAGE: 597 GRID: A4 LOCALITY: TEMPLE CITY CAI
_IO2 COMPRSR < 100 KBTU 1.00 COM 27.00
(TENANT: 108 FURNACE/HEATER <100 1.00 UNI 27.00 (ISSUED ON: PROCESSED BY: PLAN BY:
147 ALTER EXIST DUCT SYS 1.00 SYS 27.00 .111/09/12 SR 1
TOTAL FEES 108.80 1 - I
(OWNER: TEL. NO: I IFINAL DATE. FI Y: CODE:
ICOSLOFF IRVING L;TERI M (626) 285-3658- 1 I I
15127 KAUFFMAN AV I
ITEMP 9.17803946 1 ID SCRIPTION OF WORK
I ICHANGE OUT EXISTING HVAC SYSTEM (FAU, COIL, CONDENSER, AND
1 I IDUCTWORK 1
(APPLICANT: TEL. NO:
IGROSENBACH, PHILLIP (626) 358-0022- I I I
11310 S MYRTLE AVE I (SPECIAL CONDITIONS: I
IMONROVIA CA 91016 I I I
(CONTRACTOR: TEL. NO: I (APPROVALS DATE INSPECTOR SIGNATURE 1
(GENERAL HEATING AND A C, INC. - (626) 358-0022- 1
11310 S MYRTLE AVE LIC. NO - IFAU/WALL FURNACE 1 1
IMONROVIA CA 91016 469166 1 1 1 r I
1 1 ICOMBUSTION AIR OPENINGS 1
(ARCHITECT OR ENGINEER: TEL. NO: 1 - IDUCT WORK I I I
LIC. NO: 1 1AC/COMPRESSOR 1
'•�t, ... _ 1 .ITHERMOSTAT i
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I IFIRE DAMPERS ( I I
1 I ISMOKE DETECTION DEVICES I I 1
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I I ICOMMERCIAL HOOD 1 I 1
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1 t IREPORT ID: j,DPR264 ROUTE TO: BS0508 I I 1
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